Partielle Nephrektomie nach neoadjuvanter Therapie mit Sunitinib ermöglicht den Nierenerhalt bei Einzelniere

Zusammenfassung

Wir berichten über eine 66-jährige Patientin, die sich mit einer 7,1 cm messenden, in der computertomografischen Bildgebung tumorsuspekten Raumforderung einer Einzelniere links vorstellte. Hier erfolgte zunächst der Versuch der offenen chirurgischen partiellen Nephrektomie. Der intraoperative Befund erlaubte, hauptsächlich wegen der engen Lagebeziehung des Tumors zu den Hilusgefäßen, keine nierenerhaltende chirurgische Resektion. Die im Rahmen des Eingriffes gewonnene Tumorhistologie ergab den histopathologischen Befund eines klarzelligen Nierenzellkarzinoms. In Folge wurde eine Systemtherapie mit Sunitinib über einen Zeitraum von 70 Tagen (2 Zyklen/50 mg p. d.) durchgeführt. Das sich anschließende Re-Staging ergab eine Reduktion des größten Tumordurchmessers i. S. einer partiellen Remission nach RECIST (Response Evaluation Criteria in Solid Tumors) von 32%. Nach Aussetzen der Gabe von Sunitinib, konnte die Nierenteilresektion komplikationsfrei durchgeführt werden. Der postoperative Verlauf war unkompliziert. Vor Entlassung lag die glomeruläre Filtrationsrate stabil bei 48 ml/min. Die endgültige Tumorhistologie ergab ein klarzelliges Nierenzellkarzinom – pT1b, pNx, G2, R0.

Abstract

We report on a 66-year-old female patient, presenting with a renal mass of 7.1 cm diameter on CT scan indicative of malignancy in the left solitary kidney. At first, the attempt at an open partial nephrectomy was undertaken. The intraoperative findings, however, did not allow for a kidney-preserving surgical procedure, mostly due to the close proximity of the tumour to the hilar vessels. The histopathology obtained during the procedure showed a clear cell renal cell carcinoma. Thus, systemic therapy with sunitinib over a period of 70 days (2 cycles/50 mg p. d.) was initiated. The subsequent CT scan showed shrinkage of the tumour with a partial response according to RECIST criteria (response evaluation criteria in solid tumours) of 32%. After discontinuation of sunitinib therapy, a partial nephrectomy was possible without complications. Postoperative follow-up was uneventful. The glomerular filtration rate before discharge was stable at 48 mL/min. The final tumour pathology showed a clear cell renal cell carcinoma – pTNM: pT1b, pNx, G2, R0.

Schlüsselwörter

TKI - Sunitinib - neoadjuvante Systemtherapie - Nierenzellkarzinom - partielle Nephrektomie

Key words

TKI - sunitinib - neoadjuvant therapy - clear cell renal cell carcinoma - partial nephrectomy

• Literatur

• 1 Kirchner H, Merseburger AS. Nebenwirkungen von zielgerichteten Medikamenten bei der Behandlung des metastasierenden Nierenzellkarzinoms. Onkologe 2011; 17: 155-162
• 2 Harshman Lc, Yu Rj, Allen Gi et al. Surgical outcomes and complications associated with presurgical tyrosine kinase inhibition for advanced renal cell carcinoma (RCC). Urol Oncol 2011;
• 3 Hellenthal Nj, Underwood W, Penetrante R et al. Prospective clinical trial of preoperative sunitinib in patients with renal cell carcinoma. J Urol 2010; 184: 859-864
• 4 Huang Wc, Elkin Eb, Levey As et al. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors – is there a difference in mortality and cardiovascular outcomes?. J Urol 2009; 181: 55-61 discussion 61–52
• 5 Je Y, Schutz Fa, Choueiri Tk. Risk of bleeding with vascular endothelial growth factor receptor tyrosine-kinase inhibitors sunitinib and sorafenib: a systematic review and meta-analysis of clinical trials. Lancet Oncol 2009; 10: 967-974
• 6 Kamba T, Mcdonald Dm. Mechanisms of adverse effects of anti-VEGF therapy for cancer. Br J Cancer 2007; 96: 1788-1795
• 7 Klatte T, Patard Jj, Wunderlich H et al. Metachronous bilateral renal cell carcinoma: risk assessment, prognosis and relevance of the primary-free interval. J Urol 2007; 177: 2081-2086 discussion 2086–2087
• 8 Kramer M, Krege S, Peters I et al. Targeted therapy of urological tumours. Experimental field or established therapeutic approach?. Urologe A 2010; 49: 1260-1265
• 9 Miller Dc, Schonlau M, Litwin Ms et al. Renal and cardiovascular morbidity after partial or radical nephrectomy. Cancer 2008; 112: 511-520
• 10 Motzer Rj, Michaelson Md, Redman Bg et al. Activity of SU11248, a multitargeted inhibitor of vascular endothelial growth factor receptor and platelet-derived growth factor receptor, in patients with metastatic renal cell carcinoma. J Clin Oncol 2006; 24: 16-24
• 11 Motzer Rj, Rini Bi, Bukowski Rm et al. Sunitinib in patients with metastatic renal cell carcinoma. JAMA 2006; 295: 2516-2524
• 12 Thomas Aa, Rini Bi, Lane Br et al. Response of the primary tumor to neoadjuvant sunitinib in patients with advanced renal cell carcinoma. J Urol 2009; 181: 518-523 discussion 523
• 13 Thomas Aa, Rini Bi, Stephenson Aj et al. Surgical resection of renal cell carcinoma after targeted therapy. J Urol 2009; 182: 881-886
• 14 Thompson Rh, Boorjian SA, Lohse CM et al. Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol 2008; 179: 468-471 discussion 463–472
• 15 Van der Veldt Aa, Meijerink Mr, Van den Eertwegh Aj et al. Sunitinib for treatment of advanced renal cell cancer: primary tumor response. Clin Cancer Res 2008; 14: 2431-2436
• 16 Weight Cj, Larson Bt, Fergany Af et al. Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses. J Urol 2010; 183: 1317-1323